Selective laser trabeculoplasty in patients with pseudoexfoliative glaucoma vs primary open angle glaucoma: a one-year comparative study

A Review of Selective Laser Trabeculoplasty: “The Hype Is Real”

Presently, there is no efficacious treatment for glaucomatous optic neuropathy; the current treatment is focused on lowering intraocular pressure (IOP). Studies have demonstrated the safety and efficacy of selective laser trabeculoplasty (SLT) in reducing the IOP in eyes with open-angle (OAG) glaucoma or ocular hypertension (OH). Moreover, the European Glaucoma Society has instated SLT as the first-line or adjunctive treatment in OAG or OH, reiterating its clinical significance. In this review, we outline the old and the new roles of SLT, with an emphasis on clinical practice, and look further into its renewed appeal and future developments.

Selective Laser Trabeculoplasty for Medically Uncontrolled Pseudoexfoliation Glaucoma in Korean Eyes

Purpose

This study investigated the efficacy and safety of selective laser trabeculoplasty (SLT) in Korean eyes with medically uncontrolled pseudoexfoliation glaucoma (PEXG).

Methods

This retrospective observational study enrolled 43 medically uncontrolled PEXG patients who underwent a 360-degree SLT and were followed up for at least one year after SLT. The intraocular pressure (IOP) before and after SLT at 1 week, 1, 3, 6, and 12 months was evaluated. Treatment success was defined as an IOP reduction of ˃ 20% from the baseline and an IOP lower than 22 mmHg without additional anti-glaucomatous intervention. Additionally, every follow-up medical record was reviewed to assess any possible side effects of SLT.

Results

Based on the Kaplan-Meier survival analysis, the treatment success rate at one year after SLT was 41.9% (18 eyes). For the success group at the one year follow-up, SLT showed a mean IOP reduction of 10.3 ± 5.0 mmHg (from 25.6 ± 4.4 mmHg to 15.2 ± 2.9 mmHg; 39.3%, p < 0.05). Among the 25 eyes that were considered as the treatment failure group, 14 eyes underwent glaucoma filtering surgeries, 4 eyes received additional SLT, and further intervention and follow-up was refused for 7 eyes. During the overall follow-up period, there were no significant adverse events.

Conclusion

SLT is a partially effective and safe procedure for lowering IOP in Korean patients with medically refractory PEXG. Therefore, it can be considered as one of the alternative treatment modalities in patients who are at high risk for conventional filtering surgery.

Selective Laser Trabeculoplasty in the Treatment of Ocular Hypertension and Open-Angle Glaucoma: Clinical Review

Selective laser trabeculoplasty (SLT) is a glaucoma treatment that reduces intraocular pressure (IOP). Its mechanism is based on the biological effects of the selective application of laser energy to pigmented trabecular meshwork (TM) cells, resulting in increased outflow facility. Herein, we review current publications on SLT and summarize its efficacy and safety for different indications in open-angle glaucoma (OAG) and ocular hypertension (OHT) treatment. SLT effectively reduces IOP when used as a primary treatment. In patients whose IOP is medically controlled, SLT helps to reduce medication use, and when maximally tolerated topical therapy is ineffective, SLT facilitates the realization of the target IOP. SLT is a repeatable procedure for which the vast majority of complications are mild and self-limiting. With effective IOP reduction, low complication rates and the potential to repeat the procedure, SLT offers the possibility of delaying the introduction of medical therapy and other more invasive treatment modalities while simultaneously avoiding the accompanying complications. With this knowledge, we suggest that SLT be considered as an essential primary treatment option in OAG and OHT, switching to other treatment modalities only when laser procedures are insufficient for achieving the required target IOP.

Outcome After Selective Laser Trabeculoplasty for Glaucoma Treatment in a Thai Population

Purpose

The study aimed to evaluate the efficacy and predictive factors of success after selective laser trabeculoplasty (SLT) for treating various types of open-angle glaucoma in a Thai population.

Design

The study employed a retrospective cohort design.

Materials and Methods

The study retrospectively recruited Thai subjects diagnosed with open-angle glaucoma receiving first time selective laser trabeculoplasty. Primary open-angle glaucoma (POAG), ocular hypertension (OHT) and other types of open-angle glaucoma were included. Reduced intraocular pressure (IOP) of 20% or decreased number of antiglaucoma drugs usage after SLT was defined as success. Various parameters were analyzed for association with SLT success.

Results

Ninety-six eyes were recruited in the study. Mean pre- and postSLT IOP were 19.31±3.59 and 15.04±3.13 mmHg, respectively. IOP decreased significantly in all follow-up visits (p<0.001). Overall, 59.4% met the treatment endpoint. More than 10% postSLT IOP elevation at 1 hour was the only covariate positively associated with SLT success in both univariate (odds ratio (OR) = 1.042, p = 0.037) and multivariate analyses (OR = 1.040, p = 0.046). Underlying hypertension and preSLT IOP were negatively associated with SLT success in both univariate (OR = 0.970, p = 0.026, OR = 0.955, p < 0.001) and multivariate analysis (OR = 0.970, p = 0.026, OR = 0.991, p < 0.001).

Conclusion

IOP significantly decreased as well as the number of antiglaucoma drugs needed after SLT. More than 10% postSLT IOP elevation at 1 hour was a positive predictor whereas systemic hypertension and preSLT IOP were negative predictors of SLT success.

Responsiveness to ripasudil may be a potential outcome marker for selective laser trabeculoplasty in patients with primary open-angle glaucoma

We examined responsiveness to ripasudil as a potential factor for predicting the effect of selective laser trabeculoplasty (SLT) when performed for primary open-angle glaucoma (POAG). A total of 70 eyes with no history of glaucoma surgery underwent SLT between January 2015 and June 2019. Patients were divided into two groups, with an intraocular pressure (IOP) decrease of 15% or more due to ripasudil administration before SLT defined as the effective group, while an IOP decrease of less than 15% was defined as the non-effective group. Kaplan–Meier survival analysis was performed. A Cox proportional hazards model assessed the influence of baseline factors on the success. Of the 70 eyes evaluated, treatments were effective in 22 and non-effective in 48. Postoperatively, both groups exhibited IOP reductions for up to 24 months. Success ratios at 12 and 24 months after SLT were 43.5% and 18.5% in the effective versus 24.9% and 9.3% in the non-effective group, which were significantly higher in the effective group (P = 0.03). Presence of a ripasudil effective eye (P = 0.03) was associated with treatment success. Responsiveness to ripasudil may be useful in predicting the therapeutic effect of SLT.

Micropulse laser trabeculoplasty on pseuodexfoliation glaucoma patients under topical prostaglandin analogue monotherapy: 1-year results

PURPOSE

To evaluate the effectiveness of a single session of micropulse laser trabeculoplasty (MLT) to lower intraocular pressure (IOP) in patients with pseudoexfoliation glaucoma (PEXG).

METHODS

In this single-center, one-arm, prospective study patients with PEXG under prostaglandine analogue monotherapy with inadequate IOP control were treated with 360° 532-nm MLT. Patients were evaluated at 1 day, 1 month, 3 months, 6 months, and 12 months post-MLT while they were treated with the same drug regimen as pre-MLT. Mean IOP reduction and percentage of IOP change during the follow-up were calculated. Cases that required any further intervention, like additional hypotensive medication, laser or surgical therapy, throughout the study period were considered failures and removed from the study.

RESULTS

Twenty-seven eyes (27 patients, 17 male) were included in the study. The age of the patients was 72.37 ± 6.29 years and the baseline IOP was 20.41 ± 1.87 mmHg. Treatment with MLT resulted in significantly lower IOP at 1, 3, 6, and 12 months after MLT compared to baseline (p < 0.0001 for all comparisons). By the end of the study, 52.17% of the PEXG eyes demonstrated a ≥ 20% IOP reduction compared to baseline. Four eyes (14.81%) did not respond to MLT (three eyes at 3 months and one eye at 6 months after trabeculoplasty) and were considered failures since they required additional intervention.

CONCLUSIONS

Micropulse laser trabeculoplasty appears to be an effective method to lower IOP in patients with PEXG up to 12 month of follow-up period.

TRIAL REGISTRATION

The study is registered on www.ClinicalTrials.gov with registration number NCT03483402.

Lasers in glaucoma

While lasers have been used for many years for the treatment of glaucoma, proper indications and use of the procedures need to be considered before their application. This review summarizes the important laser procedures in Glaucoma.

A Review of the Clinical Usefulness of Selective Laser Trabeculoplasty in Exfoliative Glaucoma

In the last decade, selective laser trabeculoplasty (SLT) has been commonly used in the management of several different types of glaucoma, as either primary or adjunct therapy. The technique has an excellent safety profile and is at least as effective as argon laser trabeculoplasty. Although the actual mechanism of action of SLT remains unclear, evidence has shown that it does not induce morphologically evident trabecular meshwork alterations. SLT's non-disruptive mode of action offers the advantage of repeatability. Exfoliation glaucoma (XFG) is a secondary open-angle glaucoma with unfavorable intraocular pressure (IOP) characteristics, which typically carries a poorer long-term prognosis than primary open-angle glaucoma. Consequently, patients with XFG often need multiple medications to achieve IOP levels that prevent disease progression. Because complicated pharmacotherapy regimens undermine the long-term tolerability and compliance of patients with XFG, options such as SLT may decrease the burden of multiple therapies and ultimately improve prognosis. In fact, SLT may be a particularly attractive option in XFG because the pigment-laden trabecular tissue of these patients enhances the absorption of laser energy and thus augments the biologic effects induced by this treatment. The current article reviews the postulated mechanisms of action of SLT, discusses practical aspects of SLT therapy, and examines selected peer-reviewed literature pertaining to the clinical usefulness of this modality in XFG patients.

A Review of Selective Laser Trabeculoplasty: Recent Findings and Current Perspectives

Selective laser trabeculoplasty (SLT) has been widely used in the clinical management of glaucoma, both as primary and adjunctive treatment. As new evidence continues to arise, we review the current literature in terms of indications and efficacy, surgical technique, postoperative care, repeatability, and complications of this therapy. SLT has been shown to be effective in various glaucomas, including primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), steroid-induced glaucoma, pseudoexfoliation glaucoma (PXFG), and primary angle-closure glaucoma (PACG), as well as other glaucoma subtypes. Relatively high preoperative intraocular pressure (IOP) may predict surgical success, while other parameters that have been studied do not seem to affect the outcome. Different techniques for performing the procedure have recently been explored, revealing that minor modifications may lead to a more favorable or safer clinical outcome. The utilization of postoperative medications remains controversial based on the current evidence. A short-term IOP increase may complicate SLT and can also persist in certain cases such as in exfoliation glaucoma. The efficacy and safety of repeat SLT are shown in multiple studies, and the timing of repeat procedures may affect the success rate.